Improved coordination of care across health care settings and enhanced health information technology have been identified by the IOM as two essential tools for improving health care management during care transitions. Yet, health care remains fragmented and poorly coordinated across treatment settings, often resulting in preventable medication errors, unnecessary hospitalizations and emergent care visits, avoidable adverse health events and dissatisfied patients and providers. Times of care transition can be particularly difficult for the medically complex patient, particularly in rural communities. The objective of this project is to improve the process by which crucial hospital discharge information is communicated to rural patients and their outpatient rural primary care providers. Specific aims include the development, implementation and evaluation of a care transition information transfer (CTIT) system. The system will rely on the current integrated electronic health record (EHR) in a large non-profit community health system and will include electronically generated: 1) comprehensive patient discharge instructions, including a patient-friendly medication list, provided to the patient at time of discharge and sent to the rural outpatient provider clinic; and 2) discharge information transmitted to rural outpatient providers regarding their high-risk patients. Rural providers will also be prompted to access more complete medical information by connecting directly to the hospital's EHR. Program evaluation will focus on specific clinical outcomes, such as patient adherence to medication instructions after discharge, patient receipt of reconciled medication lists, hospital readmission rates, and utilization of emergent care services; system efficiency outcomes, such as time to first patient ambulatory setting visit; and rural patient/family and inpatient/outpatient provider satisfaction. The research design is an 18-month prospective controlled intervention study, within a three-year project. Both prospective and retrospective data will be obtained from several sources, including data abstracted from a hospital EHR and manual review of rural clinic medical records; questionnaires administered to rural patients at time of hospital discharge or by phone interview; and rural patient and family satisfaction surveys. Study hypotheses posit that the CTIT system will be associated with improved patient clinical outcomes, system efficiency and process outcomes, and both rural patient and provider satisfaction with the care transition process. Success in achieving project aims may have a significant effect on patient care in rural areas by providing a health information technology (HIT)-based care transition information system model that could be easily disseminated to other health care systems. Positive results could significantly alter clinical practices surrounding the care transition process, which in turn may result in improved quality of care and patient safety. Use of existing HIT translates into a low cost system change that has the potential to greatly improve patient safety and quality of care for high-risk medically complex patients in particular, who are at the greatest risk for adverse events post-discharge. [unreadable] [unreadable] [unreadable]